Power Mobility Solutions for All.pptx

INTRODUCTION
•  Describe two evidence based developmental benefits of power mobility
in children.
•  List three aspects of choosing a drive control to match the consumer’s
functional needs.
•  Compare and contrast proportional versus non-proportional drive
controls.
•  Participants will list three benefits to integrating a standing feature into a
client’s wheelchair base.
•  Participants will identify three potential medical benefits of standing.
•  Participants will identify three relevant patient applications of wheelchair
standers based on research.
PRESENTED BY AMY MORGAN, PT, ATP
7/9/14
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INTRODUCTION
•  Approved by RESNA Board of
Directors - 1/26/11
•  12 pages content
•  3 Case Examples
•  References
POWER MOBILITY SOLUTIONS FOR ALL
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ASSESSMENT
ASSESSMENT
•  Address reason for referral and desired outcome
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Primary problems issues with current mobility status
Postural Support
Health
Safety
Ability to function within the environment
•  Previous treatments and outcomes
If a person is not actively involved in the selection
process for their equipment, they are likely to
abandon that equipment.
Kittel, DiMarco, & Stewart, 2002
•  Likes/Dislikes of current equipment
•  TEAM MUST UNDERSTAND THE CLIENT’S GOALS AND
EXPECTATIONS!
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ASSESSMENT
ASSESSMENT
•  Domains:
•  Body Structure and Functions
•  Activities and Participation
•  Environment and Current Technology
•  Issues and Limitations of Current Wheelchair
•  Seating and Positioning
•  Seat Functions and their uses
•  Mobility Limitations
•  Other Assistive Technology Used
•  Especially in conjunction with wheelchair
•  Augmentative and Alternative Communication Device (AAC)
•  Computer
•  Environmental Control Units (EADL units)
World Health Organization (WHO), 2002
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ASSESSMENT
•  WC-19 vs. ISO 7176-19
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Home
School
Work
Community
Transportation
Terrains
Weather Conditions
Support System/Caregivers
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Enter/Exit settings
Maneuver within settings
Reach/Access items
Transfer to/from
wheelchair
•  Use personal or public
transportation
Major difference:
-  WC-19 uses on-board restraint belts
-  ISO 7176-19 uses vehicle mounted restraint belts
•  WC-18 and WC-20
-  Ability to test seating systems and bases independently
•  http://www.nhtsa.gov/people/injury/buses/UpdatedWeb/
topic_9/handout6.html
•  RESNA’s Position on Wheelchairs Used as Seats in Motor
Vehicles, www.resna.org
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ASSESSMENT
ASSESSMENT
•  MRADLs – Eating, Grooming, Dressing, Bathing, Toileting,
Transferring, Communicating, Engaging in Sexual Activity
•  IADLs – Safety Procedures/Emergency Response, Telephone
Use, Parenting, Directing Caregivers, Caring for Service Animals,
House Cleaning, Laundry, Meal Preparation, Use of
Transportation and Community Mobility for School, Work,
Shopping, Banking, Socializing, Recreation
•  Body Functions – physiological and psychological functions
of body systems.
•  Impairments – problems in body function as a result of
significant deviation or loss.
(World Health Organization, 2002)
NOTE: Movement pattern/technique used – ensuring wheelchair
design/components promote maximum function and safety
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•  Both need to be considered during a wheelchair
assessment.
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ASSESSMENT
ASSESSMENT
•  Subjective Assessment (Client Interview)
•  Neuromuscular System: Muscle Strength, Gross and Fine
Motor Control, Coordination, Muscle Tone and Spasticity,
Sitting and Standing Balance
•  Range of Motion and Flexibility: Pelvis, Hips, Knees, Ankles
and Spine, Skeletal Alignment/Deformity (i.e. Scoliosis)
•  Current/Past Skin Integrity Issues: Persistent Redness,
Pressure Ulcers, Open Areas, Scar Tissue
•  Current Mobility Skills: Ambulation, Manual w/c Propulsion,
Power w/c Operation (independence, safety, efficiency, etc.)
•  Cognition
•  Speech and Language
•  Cardiovascular, Respiratory, Digestive, Urinary Systems
•  Can also be assessed objectively or referred out for further evaluation
•  Objective Assessment (Mat Evaluation)
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Anatomical Alignment
Postural Control (sitting balance)
Skin Integrity
Neuromuscular System (strength, range of motion, tone, coordination,
sensation)
•  Vision
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ASSESSMENT
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Primary Diagnosis/Prognosis
Past Medical History/Secondary Diagnoses/Co-Morbidities
Past Surgical History (related to seating and mobility)
Future Surgical/Medical/Therapeutic Interventions
Have appropriate rehabilitative measures been attempted?
Medications and Allergies
POWER MOBILITY SOLUTIONS FOR ALL
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EQUIPMENT RECOMMENDATION/SELECTION
EQUIPMENT RECOMMENDATION/SELECTION
•  Generate list of functional requirements.
•  Translate that list into seating and mobility goals.
•  Determine which products offer desired capabilities and
features to support these goals.
•  Arrange an equipment trial to assist in client’s final product
selection (using a variety of options).
•  Use objective measures to compare products (photographs,
skills performance, pressure mapping, etc.)
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PEDIATRIC POWER MOBILITY: EARLIER INTERVENTION
PEDIATRIC POWER MOBILITY: EARLIER INTERVENTION
• Toys/Commercially available products
•  Walkers
• Walkers
• Tricycle/Ride on Toys
• Ride on Cars (Power)
•  Safety Concern
•  Tricycle/Ride on Toys
•  Little to no support for kids with limitations in postural
control
• Medical Devices
• Scooter Boards/Crawlers
• Ambulatory Aides (crutches/walkers/gait trainers)
• Wheelchairs (manual/power)
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•  Ride on Cars (Power)
•  Typically controlled with foot pedal and minimal postural
support
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PEDIATRIC POWER MOBILITY: EARLIER INTERVENTION
•  Scooter Boards/Crawlers
•  Fatigue/Not always practical/maneuverable
•  Ambulatory Aides
•  Fatigue/Cumbersome/Cost (funding)
THE IMPORTANCE OF EARLY EXPLORATION
•  Manual Wheelchairs
•  Cost (funding)/Effort required (manueverability)
•  Power Wheelchairs
•  Cost (funding)/Size/Weight/Difficulty transporting
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Function
Cognitive Development
Visual Development
Perceptual Development
Social Interaction
!
9 | © Permobil Corp. | www.permobil.com |
7/9/14
Any person unable to move functionally and
independently:
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In all environments
In all situations
With efficiency
With safety
10 | © Permobil Corp. | www.permobil.com
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Sensorimotor
PEDIATRIC POWER MOBILITY
• Motivation
• Understanding of cause and effect
•  Perception
•  Processing
•  Motor Planning
•  Reaction Time
Cognitive
•  Cause & Effect
•  Directional Concepts
•  Problem Solving
•  Spatial relationships
•  Judgment
•  Following commands does not teach cause and effect.
• Spatial relationships
• Problem-solving concepts
• Attention
• Physical ability to consistently and purposefully activate the
access method
Ability to
operate
PMD
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Coping
Strategies
•  Attention span
•  Motivation
•  Persistence
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PEDIATRIC POWER MOBILITY
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Evidence Based Practice:
•  Reducing the risk of learned helplessness
•  Promoting self confidence
•  Increasing learning/development
•  Allowing visual development
4-5 months: Rolling
8-10 months: Crawling
12-15 months: Walking
18-20 months: Running
2 years: Jumping
3 years: Riding a tricycle
4 years: Galloping
5 years: Skipping
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Rosen, L.; Arva, J.; Furumasu, J.; Harris, M.; Lange, M.; McCarty, E.; Kermoian, R.;
Pinkerton, H.; Plummer, T.; Roos, J.; Sabet, A.; VanderSchaaf, P.; and Wonsettler, T.
(2009). RESNA Position on the Application of Power Wheelchairs for Pediatric Users.
Assistive Technology.21(4): 218-226.
(Galloway & Meyer 2010)
11 | © Permobil Corp. | www.permobil.com
PEDIATRIC POWER MOBILITY: EARLIER INTERVENTION
Problem: 3-5 yr wait for Power Mobility
Solution: Tech + Training at 6 months
Depressed motivation, apathy and a stifling of
initiation occurs . . .
resulting in “learned helplessness”
Stancliffe S. Wheelchair services and providers: discriminating against disabled
children? International Journal of Therapy and Rehabilitation. 2003; 10(4): 152-158.
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(Logan, 2013)
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Goal Oriented Driving
Power mobility advances cognitive,
language, crawling/walking
100
80
60
40
20
0
1 -‐ B a seline
2
3
4
Wheelc ha ir
M o n t h o f T r a i n i n g
Bayley Subscale
Age Equivalent
(months:days)
Pre
(Logan, 2013)
Lynch et al. 2009 Pediatric Physical Therapy 21(4):362-8.
1) Not smart enough to learn to drive
Post
Cognition
5:0
16:0
Language: Receptive
6:0
14:0
Language:Expressive
5:0
12:0
Fine Motor
5:10
13:0
Gross Motor
5:0
7:0
2) Won’t follow adult commands
(Safety)
Galloway, APTA CSM 2009
Galloway, APTA CSM 2009
EQUIPMENT RECOMMENDATION/SELECTION
The very skills that are
required to be “safe” develop
through independent mobility.
3) Power mobility selected over walking
(Age) Appropriate
Supervision
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Galloway, APTA CSM 2009
1.  Power mobility as tool
2.  Increases options
3.  Increases daily exploration
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Mobility is a Human Right • 
When to start:
–  Specific criteria, “Readiness”
–  NOW
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What to focus on:
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Where to use:
–  Targeted movement or behavior
–  EVERYTHING
–  Controlled environments
–  EVERYWHERE
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How often?
–  2 x 3 times per week for 20-30 minutes per session led
by a PT
–  ALL THE TIME
EQUIPMENT RECOMMENDATION/SELECTION
•  Pediatric Powered Wheelchair Screening Test (PPWST)
Think Outside the Box:
Find a solution to provide a means of
independent exploration to allow for the
most “normal” cognitive development while
simultaneously working on other therapy
goals (Walking)
•  CP and Ortho
•  Joystick only
•  Peer reviewed
(Furumasu, Guerette, & Tefft, 2004)
•  Driving to LearnTM
(Durkin & Nilsson, 2010)
•  Non-peer reviewed tests
Individual funding source requirements
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EQUIPMENT RECOMMENDATION/SELECTION
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Activity &
Movement
Understanding
of Tool Use
Expressions
& Emotions
Interaction &
Communication
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Novice
Excited,
non-act,
rejection
No or vague
idea of use
Open
Neutral
Anxious
No response /
avoidance
2
Curious
Novice
Pre-act
Idea of basic
use is born
Contented
Curious
Anxious
Angry
Responds to
interactions
3
Beginner
Act
Basic use
Serious
Contented
Smile
Initiates
interactions
Durkin & Nilsson, 2010
STAGE
Explore function
Furumasu, Guerette, Tefft, 2004
PHASES
INTROVERT STAGE
“The PPWST is designed to help clinicians determine
whether a child currently has the specific cognitive
skills found to be related to powered wheelchair
driving but it is not intended to be used exclusively to
determine whether or not a child is ultimately a
candidate for powered mobility.
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Expressions
& Emotions
Interaction &
Communication
4
Advanced
Beginner
Chains of
acts
Exploration of
extended use
Serious
Smile
Sometimes
laugh
Mutual Interaction
5
Sophisticated
Beginner
Sequences
of acts
Eager
Smile
Serious
Frustration
Reciprocated
interaction
Triadic interaction
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Idea of
competent use
is born
Durkin & Nilsson, 2010
PHASES
Activity &
Movement
Understanding
of Tool Use
Expressions &
Emotions
Interaction &
Communication
6
Competent
Activity
Competent
use of tool
Serious
Content
Laugh
Excited
Consecutive
interactions
7
Proficient
Occupation
for its own
sake
Fluent
precise use
of tool
Happiness
Satisfaction
Concurrent
interactions
8
Expert
Occupation,
composed of
two or more
activities
Integrated
tool use
Dependent
on the doing
of ‘other’
activities
Multi-level
integrated
interaction
STAGE
1
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Durkin & Nilsson, 2010
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EQUIPMENT RECOMMENDATION/SELECTION
EQUIPMENT RECOMMENDATION/SELECTION
•  If possible, a short term trial of equipment is beneficial.
•  Wheelchair skills/mobility training may also be necessary to
improve safety and and independent functioning.
(Kirby et al, 2004, Best et al, 2005, & Kirby et al, 2006)
•  Once a client demonstrates the potential for safe mobility
using the trial device, a recommendation can be made and
additional training can be scheduled to maximize abilities.
•  Very important for final product selection
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EQUIPMENT RECOMMENDATION/SELECTION
EQUIPMENT RECOMMENDATION/SELECTION
•  Do the best you can at “mocking up” the
system.
•  What is the location of their most
consistent control?
•  What type of movement pattern is used?
•  Visual/Perceptual abilities/limitations
must be noted and addressed.
•  Proper positioning/support is very
important!
•  Contact manufacturers for demo equipment
•  Be creative with seating/positioning
supports.
•  Pool noodles, blanket/towel rolls, wedges, pillows
•  Rely on past experience of team
members.
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•  Trial equipment is rarely, if ever, perfect
•  May need to schedule a follow up appointment
when appropriate trial equipment is available.
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STAGE
Explore performance
Understanding
of Tool Use
EXTROVERT STAGE
Activity &
Movement
DIFFICULT
TRANSITION
Explore sequencing
PHASES
•  Front-Wheel Drive
•  Mid-Wheel Drive
•  Rear-Wheel Drive
•  Not critical for the power mobility assessment
•  Goal: To determine if the client has the potential for safe, independent, and
functional use of power mobility.
•  Use what you have available.
•  Input Device/Controls are more important than base at this point in trial.
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•  Client should not have to “work” to activate the
input device.
•  Don’t want positioning components to restrict
movement too much.
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EQUIPMENT RECOMMENDATION/SELECTION
What is the most consistent control site? (Hand, chin, head, foot,
etc?). Do different positions elicit more/less stability and control (midline
mount, raising/lowering the joystick, etc.) Control Movements With this control site, is there fine control or will ‘gross’
movements suffice? ROM How much movement is required to effectively operate the input?
What about during tilt or recline? Endurance &
Does the driver have enough endurance for the chosen input
Fatigue device? Interface A custom goal post, tennis ball, etc. •  Infinite control of speed (0-max) and 360° of direction
•  Continuous and fluid response while moving further from neutral
•  Non-Proportional (Switched, Digital) Controls
•  Either ON or OFF
•  Up to 8 discrete directions (Fwd, Rev, Left, Right, and every 45°
between)
•  Can be programmed for single or multiple speeds
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Considerations Issue Stability &
Consistency Location •  Proportional Controls
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less
less
Single
Switch
Stability,
Control,
AROM,
Endurance
Multiple Switches
EADLs
SIDs
(Drive Controls)
Stability,
Control,
AROM,
Endurance
Seat Function Control (Tilt/Recline/
ELRs)
Specialty Input Device (SID):
Proportional Input
Standard Joystick
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more
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more
Performance Adjustments (speeds, ACC/DEC,
Joystick Throw, etc.)
Proportional Joysticks and Handles
Proportional SID’s
Video Game Controller
Switch-It Micropilot
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Non-Proportional SID’s
Sip-n-Puff/Head Array
Active Touch
Microswitch
Other Switch Options
Head Array
Fiber Optics
EQUIPMENT RECOMMENDATION/SELECTION
EQUIPMENT RECOMMENDATION/SELECTION
•  Therapist, Supplier, or Parent/Caregiver use the chair first
•  Start in a small, familiar place (preferably indoors)
•  Going and stopping
•  Only provide a switch in one direction to start
•  Demonstrate the chair functions
•  Do not direct too much
•  Be Quiet!
•  Usually turning - Circles
•  Control the speed
•  The client is going - not driving
•  When she stops touching the switch she is stopping
•  Not too slow that it won’t respond
•  Wheelchair need to be predictable and responsive
•  Know how to program appropriately
•  Increase acceleration/deceleration for more immediate response
•  When is this appropriate?
•  When is this NOT appropriate?
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PEDIATRIC POWER MOBILITY
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PEDIATRIC POWER MOBILITY
Therapy Balls/Bolsters
Bubble Wrap
Dim lighting
Use of lights/colors
Not reward based
Going to something – have a purpose!
• Motivation is key
• Parent/Sibling/Peer Motivation
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•  Watch for the response!
Visually
Emotionally
Facial expressions
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Not just line following
Need to teach in variety of environments
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Avoid directions and chatter
Indoors and outdoors
Avoid distractions and standing too close
•  Start with small, familiar space
•  Client needs to know that they are responsible for the action
•  Don’t interrupt unless necessary
•  Allow them to “interact” with the environment
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PEDIATRIC POWER MOBILITY
•  Function:
“the actions and activities assigned to, required of,
or expected of a person.”
POWER MOBILITY SOLUTIONS FOR ALL
•  Therapy (Exercise):
“treatment of illness or disability”
•  (American Heritage College Dictionary, 3rd Edition. 1993)
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PEDIATRIC POWER MOBILITY
PEDIATRIC POWER MOBILITY
•  Pros:
•  Provides mobility for children who
cannot walk or use ambulation
aides
•  Typically easily transported
•  Provide upper extremity strength/
endurance/ROM
•  Children can interact with peers
(low seat to floor height, etc.)
•  Adapted Strollers
•  Tilt-n-Space Manual
Wheelchairs
•  Lightweight/Ultra-lightweight
Manual Wheelchairs
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PEDIATRIC POWER MOBILITY
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Cons:
•  Postural supports may interfere with
propulsion
•  Limited distances?
•  Limited environments?
•  Chair weight often exceeds user
weight
•  Fatigue/Energy required?
•  Independence?
•  Safety? Shoulder preservation?
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PEDIATRIC POWER MOBILITY
•  Scooters
• Group 1
•  Power Wheelchairs
• Group 2
• Group 3
• Group 4
• Group 5 - Pediatric
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•  Pros:
Cons:
•  Energy conservation
•  Minimal effort for mobility
•  Increased speed and efficiency of
movement
•  Access to more environments/
terrains
•  Postural supports do not interfere
with mobility
•  Children can interact at peer level
(esp. with power seat functions)
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Transportation challenges
Appears most “disabled”
Size/weight of wheelchair
Safety?
Perception that child will lose
interest in walking
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PEDIATRIC POWER MOBILITY
PEDIATRIC POWER MOBILITY
•  Slow gait speed to “normalize” energy
•  If assistive device increases energy requirement – it will not
be used
•  “Children with Myelomeningocele . . .
•  Ambulation 218% less energy efficient than non-disabled
peers
•  Energy expenditure was significantly lower during
wheelchair propulsion than during walking
•  Wheelchair propulsion was as fast and as energy
efficient as normal walking”
• 
(Fischer & Gullickson, 1978)
•  CP ambulation
• Half velocity of age-matched non-disabled peers
• More oxygen consumption per kg/min
• 
(Campbell & Ball, 1978)
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•  (Williams et al., 1983 as cited in Campbell SK, 1994 p. 640)
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PEDIATRIC POWER MOBILITY
PEDIATRIC POWER MOBILITY
•  Myelomeningocele (MM)
•  Wheelchair propulsion required 42% less energy than
crutch walking at the same speed.
•  Oxygen consumption only 9% higher in children with MM
compared to non-disabled peers at usual walking speed.
•  Children with Myelomeningocele using 2 different orthotic
devices
•  Similar heart rate (HR) with 2 orthoses
•  Slower velocity and shorter distances with household
ambulators vs. community ambulators
• 
•  Self regulation of HR
(Agre et al., 1987 as cited in Campbell SK, 1994 p. 640)
•  Effect on school/job performance?
•  Decline in visuomotor accuracy with ambulation
• 
•  All children showed higher HR than non-disabled peers
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(Franks et al., 1991)
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(Bartonek et al., 2002)
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PEDIATRIC POWER MOBILITY
PEDIATRIC POWER MOBILITY
•  Manual Wheelchair Use
•  Childhood Onset (CO) vs. Adult Onset (AO)
• Similar Lifestyles
• Subjective Pain Measurements
• AO wheelchair users reported greater pain
• Immature skeleton respond to repetitive forces better
• CO have less “injury free” reference point
•  They are NOT the same
•  We must differentiate between the two!
•  Prescribe a functional mobility device
•  Examples:
•  Driving to gym or park/trail to run
•  Imagine running everywhere you go . . .
•  How alert are you when you get there?
•  Would you be able to function/interact?
(Sawatzky et al., 2005)
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PEDIATRIC POWER MOBILITY
PEDIATRIC POWER MOBILITY
•  How might the mobility device
•  Compression Forces
•  Assist/Impede bone growth/development?
•  Affect alignment?
•  Perpendicular – stimulate lengthening
•  Shear Forces
•  How will the mobility device affect strength, ROM, disease
progression?
•  How will the mobility device affect the child’s long term
needs?
•  Parallel – torsional/twisting changes
• 
•  UE Preservation
•  FUNCTION!!
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(Arkin & Katz, 1956; LeVeau & Bernhardt, 1984)
•  “the final bone shape develops throughout early childhood
under the influence of the forces of movement and
compression.”
• 
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(Drachman & Sokoloff, 1966 as cited in Campbell SK, 1994 p. 107)
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PEDIATRIC POWER MOBILITY
•  Hip
•  Weight bearing
•  Acetabular depth
•  Risk of hip dysplasia in
children with CP
(Heinrich et al., 1991)
•  Shoulder
•  Biomechanics of propulsion
•  Wheelchair set up
(Brubaker, 1986; PVA, 2005)
•  Overuse Injury
•  Think future!
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POWER MOBILITY SOLUTIONS FOR ALL
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•  Standing wheelchairs are too diﬃcult to jus4fy for funding. •  There are no diﬀerences between a standing wheelchair and separate standing frame.
•  “Sorry, it’s been too long since you’ve stood so a standing wheelchair is contraindicated.” 7/9/14
Truth is . . .
•  Lack of knowledge •  Lack of resources •  Lack of perseverance •  Lack of desire •  Lack of commitment WWW.PERMOBIL.COM
•  AKer 6 weeks of bed rest •  Three Main Reasons –  Decreased Bone Mineral Density (BMD) –  Risk of Pressure Ulcers –  Development of Joint Contractures –  Impaired bowel and bladder func4oning –  Impaired respiratory func4oning –  Gastro-‐Intes4nal problems –  Health Beneﬁts –  Func4onal Beneﬁts –  Social Beneﬁts Deitrick J, Whedon G, Shorr E. Eﬀects of immobiliza4on upon various metabolic and physiologic func4ons of normal men. American Journal of Medicine, 1948; 4: 3. •  Study by the American Cancer
Society followed 123,216 individuals
from 1993-2006.
–  Women who were inactive and sat over
6 hours a day were 94% more likely
to die during the time period studied
than those who were physically active
(68% for men).
–  These findings were INDEPENDENT
of physical activity levels (negative
effects were just as strong in
individuals who exercised regularly).
•  Spinal Cord Injury (SCI)
Should NOT be diagnosis driven…
•  Spina Bifida
•  Brain Injury
Anyone who is unable to change
their body position nor stand
upright on their own may be a
candidate for a standing device.
•  Stroke (CVA)
•  Cerebral Palsy (CP)
•  Neuromuscular Diseases
http://www.juststand.org/
tabid/674/language/en-us/
default.aspx
• 
• 
• 
• 
Primary Lateral Sclerosis (PLS)
Muscular Dystrophy (MD)
Spinal Muscular Atrophy (SMA)
Multiple Sclerosis (MS)
Evidence Based Practice (EBP)
Current
Research
+
Clinical
Experience
=
Best
Practice
(Andriaasen, Asbeck, Lindeman, vand der Woude, de Groot, & Post, 2013)
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•  Bone Mineral Density
–  Dynamic Weight Bearing – Shorter, More Frequent
•  GI/Respiratory/Circulatory
–  Frequency of Standing
•  Bowel/Bladder
–  Reducing UTI/kidney stones/constipation/bowel accidents
•  Spasticity
SCI triggers rapid loss of BMD in both the trabecular bone and
cortical cross sectional area (shaft of the bone).
•  Studies have shown that as much
as 15%-35% BMD in the LEs was
lost during the first year post injury.
–  Immediate and significant effect
•  Contractures
–  Providing prolonged stretch
•  Pressure Management
–  Reduced frequency when using stander – Best pressure relief overall
•  Steady state reached at 4 years
post SCI at ~50% BMD of healthy
controls.
(Dudley-Javoroski & Shields, 2012)
•  54 subjects divided into 2 groups:
–  Standing
–  Non-Standing
•  After 1st year: LE BMD decreased 19.62% (standing); 24% (nonstanding)
•  After 2 years: Standing group had significantly higher BMD than
non-standing group
Conclusion: SCI patients who stood at least 1 h/day; at least 5 days/
week, had significantly higher BMD in the lower extremities after 2
years compared to patients who did not perform standing.
(Alekna, Tamulaitiene, Sinevicius, & Juocevicius, 2008)
Non-ambulant children and adults with CP
are prone to low trauma fractures. This is
thought to be due to decreased BMD.
•  Longer standing programs improved
vertebral BMD. No significant affect on
proximal tibial BMD. (n=26)
(Caulton, Ward, Alsop, Dunn, Adams, & Mughal, 2004)
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•  n=38 (standing group) / n=15 (non-standing)
versus healthy controls
•  BMD in lumbar spine and femur decreased in
all individuals with SCI as compared to
controls
•  Standing vs. non-standing: Standing group
had improved BMD in the lumbar spine
(Goemaere, Van Laere, De Neve, & Kaufman, 1994)
•  Chart review (n=482) for patients with acute SCI
admitted between 1990-1995.
•  44 patients (9%) developed contractures during initial
hospitalization.
–  30 Tetraplegic; 14 Paraplegic
–  Pressure Ulcer – more likely (14.1%)
–  Spasticity – more likely (12.7%)
–  Co-existent or suspected head injury (15%)
(Dalyan, Sherman, Cardenas, 1998)
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•  n= 6; Dx: Secondary Progressive MS
•  Pilot Study - Compared daily standing x30 min. for 3 weeks and an
exercise program for a 3-week period.
–  Subjects were their own controls
•  Significant ankle and hip ROM improvements in standing compared
to exercise.
•  No significant difference in spasticity between groups (downward
trend noted with standing).
(Baker, Cassidy, & Rone-Adams, 2007)
•  Single Case - T12 SCI
•  Tilt table used 5 non-consecutive days
•  Immediate and significant effect on spasticity
lasting until the following morning
•  Particularly useful to improve car transfers
•  Indication for wheelchair stander allowing
management of spasticity when needed
(Bohannon, 1993)
•  Single case study - 62 y/o male with T12L1 ASIA B paraplegia
•  Injured in 1965 - chronic constipation
•  Standing table 5x/week - 1 hour duration
•  Significant increase in frequency of BM’s
•  Significant decrease in bowel care time
(Hoenig, Murphy, Galbraith, Zolkewitz, 2001)
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•  Patients with Stroke - Spastic Hemiplegia (n=17)
•  Single session prolonged calf muscle (triceps
surae) stretch x 30 min. on tilt table
•  Significant improvement in dorsiflexion ROM as
well as increased motor neuron excitability of
tibialis anterior.
(Tsai, Yey, Chang, Chen, 2001)
•  4 subjects with SCI (T6, T5-6, C2-5, C5) completed
12-wk exercise with dynamic weight bearing (DWB).
•  Surface EMG, HR, BP measured throughout
•  Conclusion: Exercise during DWB can induce
positive physiologic and neuromuscular responses
and may serve as preparation for more advanced
rehabilitation.
(Edwards & Layne, 2007)
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8 men; 2 women (Range: 19-56 y/o)
n=10. Incomplete C5-C7 SCI
6 - Early Group (within 6 months post SCI)
5 - Late Group (12-18 months post SCI)
Compared tilt table (at least 20 min) with strengthening
exercises
•  Both groups – tilt table greater impact on Calcium balance in
urine than strengthening
–  Early group with more significant results
(Kaplan, Roden, Gilbert, Richards, & Goldschmidt, 1981)
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•  Patients in ICU who had been intubated and
mechanically ventilated more than 5 days (n=15)
•  Tilt table to 70 degrees x 5 minutes
•  Significant improvement in respiratory parameters
during and immediately after tilt table.
•  Not present 20 minutes later.
(Chang, Boots, Hodges, Thomas, Paratz, 2004)
•  What are the recommended guidelines for
performing pressure relief?
•  How many hours do you think the average
power wheelchair user spends in the chair?
•  How often do you think the users tilt their chair?
•  How often do you think the users tilt their chair to
relieve pressure?
•  Compared tilt, recline, and standing - looking at
seat and backrest pressure
–  6 Able-Bodied (AB) and 10 Subjects with SCI
•  Maximum decreases in seat pressure in full
standing and full recline. Standing reduced both
seat and backrest pressure.
(Sprigle, Mauer, & Sorenblum, 2010)
Edlich et al. (2004) recommends power wheelchair standing
for those who are able to tolerate weight bearing for
prevention and treatment of pressure ulcers.
•  How often does one need to stand in order
to experience the benefits?
–  3 days/week? 5 days/week? Everyday?
•  For how long?
–  1 hour? 30 minutes?
(Sonenblum & Sprigle, 2011)
•  Review study in 2013 stated that children
with neuromuscular dysfunction could benefit
from standing 5 days/week
–  Improve BMD: 60-90min/day
–  Improve hip biomechanics: 60min/day in 30-60
degrees of hip abduction
–  Improve ROM: 45-60 min/day
–  Minimize spasticity: 30-45 min/day
(Paleg, Smith, & Glickman, 2013)
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•  A 2010 review study of supported standing
programs for both pediatric and adult
neuromuscular populations
•  Goal Dosage: total of 1 hour - 5 days/week
–  BMD: moderately strong evidence
–  Decreasing hypertonicity: some support
–  ROM: some support
–  Whole body vibration: promising trend but
inconclusive
(Glickman, Geigle, & Paleg, 2010)
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•  “Loading delivered in a manner that subjects
could administer themselves was useful in
alleviating the normally occurring decline in BMD.”
•  “Frequent low-intensity strains build BMD”
(Dudley-Javorski & Shields, 2008)
•  High frequency and low level mechanical stimuli
were capable of augmenting bone mass and
morphology.
(Rubin, Sommerfeldt, Judex, & Qin, 2001)
•  8 month duration - Children with
Spastic CP
•  Activity Group (n=9) had
significant increase in BMD
(femoral neck)
•  Control Group (n=9) had notable
loss in BMD (femoral neck)
(Chad, Bailey, McKay, Zello, Snyder, 1999).
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Getting in/out of standing multiple times
Vibration Platforms
Muscle contraction (Electrical Stimulation)
Weight Shifting (functional UE activities)
Standing while moving (power wheelchair)
. . . Just to name a few!
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•  Right forelimbs of adult rats loaded
360 cycles, 3 days/week, 4 months
duration (16 weeks)
–  Group 1 - 360 cycles at one time
–  Group 2 - 90x4 cycles (3 hours between)
•  Loaded limbs (Right) - significantly
greater bone density
•  Group 2 - significantly greater bone
density
•  Conclusion: Shorter duration with
periods of rest may be better for bone
density
(Robling, Hinant, Burr, & Turner, 2001)
•  Post-Menopausal Women (n=28)
•  Reciprocating Whole Body Vibration (WBV) platform
compared to Walking Activity
•  3x/week for 8 months
•  BMD at femoral neck and balance improved with WBV
- not with walking; BMD at lumbar spine did not
change in either group.
(Gusi, Raimundo, & Leal, 2006)
•  Ambulation/Ambulatory Aids
– Quality of weight bearing?
– Upper extremity support required?
•  Separate Standing Devices
– Static or Dynamic
•  Wheelchair Standing Devices
– Manual/Manual
– Manual/Power
– Power/Power
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•  Tilt table stand
(lay-to-stand)
•  Semi-reclined stand
(“loose” sit-to-stand)
•  Tight sit-to-stand
•  How often are individuals participating in a
supported standing program?
–  Survey studies
–  Case studies
–  Clinical experience
http://caribbeanweightwatchers.files.wordpress.com/
2011/05/treadmill-with-clothers-on-it.jpg
Dunn et al. (1998)
•  National survey study of individuals with a SCI who
had a separate standing device (n=99; 32% response
rate)
•  77% paraplegia
•  84% reported using their standing device
–  41% reported using it 1-6x a week
–  67% stood for 30min-1hour each time
•  Single Case – 25yo man with T10 complete
paraplegia. Standing Wheelchair monitored x 2
years
•  Exceeded recommended minimum dosage
(130.4%)
•  Short duration (Mean = 11.57 minutes)
•  Average 3.86 days/week
•  Reported improved spasticity and bowel motility
(Shields & Dudley-Javoroski, 2005)
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Eng, Levens, Townson, Mah-Jones, & Bremner
(2001)
•  Surveyed the use of separate standing devices in
individuals with SCI. n=126
•  30% stood on average 40min/session, 3-4x week
•  Most common reason for not participating in a
standing program – cost of device
•  Dunn et al. (1998): Respondents reported improved bladder
emptying, bowel regularity, decreased UTIs, leg spasticity,
and less “bed sores”. 78% “highly recommend” the use of
the standing device
•  Survey by Walter, et al. (1999). Found improvements in
QOL, fewer bed sores, fewer UTIs, improved bowel
regularity, improved LE ROM. Benefits were seen even if
standing began several years after injury
•  Survey by Eng et al. (2001) perceived benefits included
improved well-being, circulation, skin integrity, bowel/
bladder function, digestion, sleep, pain, and fatigue.
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•  6 paralyzed men from VA (average 19 years in w/c)
•  Use of static standing frame
•  Avg. Standing time - 144 hours over a mean of 135
days
•  No significant improvements in ROM, Spasticity or
Bone Density
•  Positive psychological impact noted and men
continued to uses standing frame because it made
them “feel” healthier.
(Kunkel et al., 1993)
•  Improves ver4cal range of reach –  Kitchen counters/cabinets, medicine cabinets, refrigerator, sinks, drawers, closets, thermostat, light switches, window shades/
blinds, etc.) •  Improves produc4vity at work or school •  Improves psychological well being •  Improves performance of MRADLs (ADLs/IADLs) –  Toile4ng, Feeding (cooking), Dressing (access to closets/drawers), Grooming (access to mirrors/sinks), Bathing (access to supplies) •  Funding Challenges
•  Positioning Challenges
–  Sitting and Standing
•  Bone Density Requirements
–  Safety
•  Complexity of Equipment
•  Range of Motion Requirements
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Gain medical benefits of weight bearing in upright position
Perform functional activities in standing position
More natural position (esp. pressure redistribution)
Reduce amount of caregiver assistance required
–  Often paid attendants
•  Improved compliance with standing program
•  Provide energy conservation
–  Less transfers required
•  Psycho-social benefits
•  Supports clients self-chosen desire to stand
–  Improved autonomy
•  Improves compliance with standing program
(Shields, 2005)
•  Promotes func4onal independence
•  Greater medical benefits of weight bearing
(Robling, 2001; Eng, 2001)
– Higher Frequency
– Dynamic Loading
•  Provides natural means of pressure relief (Sprigle, 2010)
– Reducing risk of pressure ulcers
– Helps heal/treat current pressure ulcers
•  Standing sequence used and set up of equipment
is CRITICAL to manage positioning.
•  Advanced programming and shear-reducing
(sliding) backrest also help control for shifting in
seating system.
•  Contractures (if not severe) CAN be
accommodated in the standing wheelchair if
providing programmable electronics.
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•  Fractures typically happen with abnormal force
–  Not usually in controlled standing situation
•  Use tilt table to determine standing tolerance and
progression
–  Obtain physician clearance
•  Lay to Stand sequence (power standing) will
minimize risk more than abrupt Tight sit-to-stand.
•  Best comprehensive overall summary of research examining
wheelchair standers.
•  Updated version with new research approved December,
2013.
–  Originally approved in March, 2007.
•  2009 - published in peer-reviewed journal.
•  Benefits, Indications, Contraindications, Case Studies (CP,
MS, SCI)
•  Available online as a free resource.
(Dicianno, et al., 2013; Arva, et al., 2009)
Talk about it as an option!
Funding source
Manufacturer
Wheelchair Supplier
Clinician
Consumer
EQUIPMENT RECOMMENDATION/SELECTION
Be a patient
ADVOCATE!
•  Team Input – Client Decision
•  Discuss all options – including those not routinely covered by the
client’s funding support.
•  Discuss funding coverage criteria, benefit requirements and
limitations.
•  Prioritize features and components desired.
•  Discuss items that may be added later when funding becomes
available.
•  Focus on client goals and functional outcomes identified at the
beginning of the assessment.
Funding source
should not dictate
what equipment is
prescribed.
CHOICE
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EQUIPMENT RECOMMENDATION/SELECTION
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Written by evaluating clinician
Client-Specific – referring to identified problems and goals
Communicate client’s physical, functional, and environmental needs
Include limitations of current equipment
Goals of the new wheelchair/seating technology
Recommendations and rationale for each item
Indicate why other less-expensive or standard options would not meet
client’s needs
•  Briefly list other products that were evaluated and failed or considered
and ruled out.
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Semantics . . . LMN Language
•  Prevent
•  Maintain
•  Reduce the risk of
•  Provide appropriate
•  Non-functional (unsafe) ambulation
•  Limited ambulation or
Household ambulation
•  Increase comfort
•  Promote ease of caregiver
assistance
•  Allow participation in
recreational activities
•  Optimal
•  Increase time tolerated decrease
pain
•  Improve safety for client and
caregiver
•  Allow participation in daily activities
•  Adequate/Appropriate
EQUIPMENT RECOMMENDATION/SELECTION
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Pain Scales
Respiratory Function Measures
Functional Performance Measures
User Satisfaction Measures
•  Usually surveys
•  Quality-of-Life Measures
•  Photographs
Necessary to compare technology and evaluate the service delivery
structure and process. (Cook & Polgar, 2008)
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§  Medicaid – State specific but regulated by and
POWER MOBILITY SOLUTIONS FOR ALL
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subject to federal law.
§  Medicare – National/Local Coverage
Determination (NCD/LCD)
§  Private Insurance – Policies vary and decisions
can be challenged
§  Veteran s Administration (VA) – Funding available
with good justification of need
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§ 
§  Prior Authorization (PA)
§  Cannot use non-covered benefit
as a reason
for denial – must be based on individual medical
necessity
§  Cannot discriminate (age, life expectancy, etc.)
§  Statutory Purpose: to furnish rehabilitation and
other services to help such families attain or
retain the capability for independence or self
care. 42 U.S.C. § 1396 (2)
•  Not a government run program
•  Pre-existing conditions can no longer be refused
•  80/20 rule – Insurance companies must spend at least 80 cents
of every dollar on health care rather than admin costs. = More
approvals
•  Caps – Under the health care law, health plans can no longer put
dollar limits on the amount of care they will cover in a year or in
your lifetime, as long as you get that care from an in-network
provider and the services are part of the essential health benefits.
•  Age - You can keep dependents on your policy until they are 26.
the evidence is adequate to determine that MAE
is reasonable and necessary for beneficiaries who
have a personal mobility deficit sufficient to impair
their participation in mobility-related activities of
daily living (MRADLs) such as toileting, feeding,
dressing, grooming, and bathing in customary
locations within the home.
§  Determination of the presence of a mobility
deficit will be made by an algorithmic process,
Clinical Criteria for MAE Coverage, to provide the
appropriate MAE to correct the mobility deficit.
280.3 - Mobility Assistive Equipment (MAE) (Effective May 5, 2005)
§  Non-Covered
•  Definition of Durable Medical Equipment (DME)
•  Definition of Medical Necessity
•  Definition of Excluded Items
–  Anything not determined to be medically necessary (for example:
standers, seat elevators, etc.)
§  Experimental or Investigational
•  Use research
•  Use client experience and results as evidence
§  Must be challenged
§  Use policy specific language and research
FUNDING/PROCUREMENT
§  Age-Based Denials – cite previous court cases
§  Estaban v Cook, 77 F. Supp. 2d 1256 (S.D. Fla. 1999) –
$582 cap on wheelchairs for beneficiaries over 21 years
ruled unreasonable.
§  Fred C. v Texas, 988 F. Supp. 1032 (W.D. Tex. 1997) –
State may not deny treatment solely based upon age as
there is no rational basis for distinguishing between those
over and under 21.
§  Hunter v Chiles, 944 F. Supp. 914 (S.D. Fla. 1996) – Age
as sole criterion is wholly unrelated to medical necessity
and is unreasonable.
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•  Ensure Coverage Criteria,
Policies, Protocols are followed
•  When a limitation exists, this is
discussed with the client
•  If a claim is denied, this should
be discussed with the client and
an appeal strategy developed
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•  Help the consumer fight for what is deserved
•  Read the denial letter outlining specific reason for denial
•  Quote that reason in the appeal letter
–  Self Advocacy!
•  Most insurances have appeals policy in writing – usually 0-90
days
•  MUST have denial in writing
•  Make sure you understand reason
for denial (missing info, more data needed)
•  Send them what they are asking for
•  Clearly address that reason for denial
•  Use research if available
•  Use State and Federal laws (court cases)
Making people with disabilities more dependent on others when
interventions exist to allow them to be more independent is
inappropriate and violates federal law and all existing standards
of practice in the field of rehabilitation. – Schmeler/Morgan
–  Nothing more!
•  We can help – use your resources!
PRODUCT PREPARATION
POWER MOBILITY SOLUTIONS FOR ALL
•  Once equipment is received, it
should be assembled and set-up
according to the preliminary
specifications.
•  Features should be tested and
inspected to ensure they are in
good working order.
•  Baseline programming of
electronics should be done prior
to the delivery appointment.
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FITTING/TRAINING/DELIVERY
•  Fitting – adjustment of the mechanical components of the
wheelchair and seating components to optimize the client’s
function, comfort, and safety.
•  Training – client education regarding safe use of the
equipment in accordance with seating and mobility goals
•  Delivery – final check of the equipment, provision of
necessary documentation (warranty, owner’s manual, etc.,
and official transfer of the wheelchair to the client’s
responsibility.
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FITTING/TRAINING/DELIVERY
•  Critical step that is often neglected
•  Scheduling difficulties
•  Especially at the end of the month/
year
•  Billing Issues/Productivity
Requirements
•  Taking quantitative outcome
measures can help make time
“billable”
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•  Historically hasn’t been
“standard of practice”
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FOLLOW-UP/MAINTENANCE/REPAIR
•  Reassess Body Structures/Function,
Activities/Participation, Environment,
Current Technology
•  Changes –
• 
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POWER MOBILITY SOLUTIONS FOR ALL
Weight gain/loss
Growth
Disease progression
Improvement in motor/sensory status
Onset of new medical issues
Problems integrating chair into new environments
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FOLLOW-UP/MAINTENANCE/REPAIR
•  Client should inspect equipment often to identify a problem
before it becomes an emergency
•  Scheduling maintenance/inspection with the supplier at
regular intervals is recommended
POWER MOBILITY SOLUTIONS FOR ALL
• 
• 
• 
• 
How often depends on complexity of equipment
Check appropriate fit
Check function of mechanical and electronic components
If modifications are needed – a member of original evaluation team should
be notified!
•  If no modifications, repairs can be done by technician
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OUTCOME MEASUREMENT
•  Standardize and validated measures are preferred
•  Allows comparison across clients, types of equipment, and delivery models
•  Baseline measurement prior to intervention and then again
at delivery.
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Client satisfaction with his/her ability to perform tasks
Ease, efficiency, and speed of mobility
Postural alignment
Pressure distribution
Sitting tolerance
Physiological abilities (breathing, swallowing, digestion, comfort)
Problem:
Funding for wheelchairs continues to diminish = People
are not getting wheelchairs that work best in their lives.
Why?:
•  Insurance entities do not value wheels.
(deny, deny, deny – counting on us giving up)
•  No fancy and expensive lobbyist for wheelchairs
•  Until now, no disability orgs concentrating on
complex rehab technology.
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Continue to develop and sustain
an educated grassroots network
of consumers, family, advocates,
and healthcare professionals.
•  Wheelchairs are NOT
expensive.
•  Medications are far more
expensive per year than
mobility equipment
1.  Register everyone at www.usersfirst.org
“Join with us” button
2.  “like” UsersFirst on Facebook
www.facebook.com/UsersFirstAlliance
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3.  Use the Mobile Registration Form “Save the
Wheelchair” button on website.
•  Thorough assessment will help guide team decision making
•  Clinical observation (movement patterns/tone) will help
determine appropriate access method and location.
•  Trial of equipment is essential and may take several
sessions to determine best access.
•  Look for the potential to be independent driver – don’t
expect perfection in a trial period.
•  Provide opportunities to promote greater independence.
•  Follow up and Education are keys to success!
•  Don’t give up! Use appeal strategies when equipment is
denied.
POWER MOBILITY SOLUTIONS FOR ALL
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